Stroke Flashcards
How do intracerebral haemorrhages and ischeamic stroke present differently?
Patients suffering intracerebral haemorrhage will tend to present with a headache whilst those suffering ischeamic stroke generally will not
What are the 2 types of stroke?
Haemorrhagic
Ischaemic
Do strokes tend to present suddenly or gradually?
Sudden onset
What are the risk factors for stroke?
High BP Previous stroke or TIA Cardiac conditions (e.g. MI, AF or IHD) Lifestyle (e.g. smoking, alcohol) Diabetes Family history Hypercholesterolaemia
What can cause an ischaemic stroke?
1) Lack of perfusion due to severe stenosis of carotid or basilar artery
2) Emoblism to the brain (of cardiac or aortic origin)
What is a lacunar infarction?
Microstenosis of the small deep arteries
What is “watershed infarction”?
Lack of perfusion affects more distal areas before the most proximal (so areas on the border between two areas supplied by different cerebral arteries are most vulnerable to ischaemia even if infarct is located far away)
What are the causes of an embolism to the brain?
Atrial fibrillation Recent acute MI Bacterial endocarditis Valvular disorders Cardiac tumours
What can cause an intracranial haemorrhage?
High BP Warfarin Trauma Ruptured cerebral aneurysm Arteriovenous malformation Cocaine/ methamphetamine use (due to severe hypertension) Bleeding tumours Bleeding disorders (e.g. haemophilia)
What is the Oxford/ Bamford stroke classification?
TACS = total anterior circulation stroke PACS = partial anterior circulation stroke LACS = lacunar syndrome POCS = posterior circulation stroke
What is a Total Anterior Circulation Stroke (TACS/TACI)?
Large cortical stroke in middle/ anterior cerebral artery areas
Causes unilateral weakness, homonymous hemianopia and higher cortical dysfunction (e.g. speech and visuospatial problems)
What is a Partial Anterior Circulation Stroke (PACS/ PACI)?
Cortical stroke in middle and/or anterior cerebral artery areas
Causes 2 of: unilateral weakness, homonymous hemianopia, higher cortical dysfunction
What is lacunar syndrome (LACS/ LACI)?
Small vessel disruption (no evidence of larger scale cerebral dysfunction)
Causes 1 of: unilateral weakness, pure sensory OR pure motor, ataxic hemiparesis
What is a Posterior Circulation Stroke (POCS/ POCI)?
Affects brainstem or cerebellar arteries.
Causes 1 of: bilateral sensory or motor deficit, cerebellar/ brainstem signs, isolated homonymous hemianopia, cranial nerve palsy with contralateral motor/ sensory deficit
What symptoms would dysfunction of the vestibular nuclei cause?
Vestibular system effects (vomiting, vertigo, nystagmus)
What symptoms would dysfunction of the inferior cerebellar peduncle cause?
Ipsilateral cerebellar signs (ataxia, dysmetria, dysdiadochokinesia)
What symptoms would dysfunction of the lateral spinothalamic tract cause?
Contralateral deficits in pain and temperature sensation from body
What symptoms would dysfunction of the spinal trigeminal nucleus/ tract cause?
Ipsilateral deficits in pain and temperature sensation from face
What symptoms would dysfunction of the nucleus ambiguus cause?
Ipsilateral laryngeal, pharyngeal and palatal hemiparalysis; dysphagia; hoarseness; absent gag reflex
What symptoms would dysfunction of the descending sympathetic fibres cause?
Ipsilateral Horner’s syndrome (ptosis, miosis + anhidrosis)
What are some common stroke symptoms?
Weakness/ paralysis/ numbness on contralateral side Vertigo/ dizziness Headache Faintness/ confusion Speech problems Difficulty swallowing Cognitive/ memory problems
What is the management pathway for stroke?
- Treat stroke
- Secondary prevention
- Manage complications
- Rehabilitation
What is the acute management of stroke?
Determine whether stroke is ischaemic or haemorrhagic (history + imaging)
Aspirin
Temperature/ Glucose levels/ BP
Thrombolysis (if indicated)
When should brain imaging be undertaken?
- Indication for thrombolysis or early anticoagulation treatment
- On anticoagulant treatment
- Known bleeding tendency
- GCS <13
- Unexplained progressive or fluctuating symptoms
- Papilloedema, neck stiffness or fever
- Severe headache at onset of stroke symptoms
What is the time difference between ‘immediately’ and ‘as soon as possible’ for brain imaging in suspected stroke patients?
Immediately = within 1 hour ASAP = within 24 hours (when there is no indication for immediate brain imaging)
What medication is recommended for thrombolysis treatment in ischeamic stroke patients?
Alteplase
What conditions are required for using thrombolysis treatment?
- Treatment started within 4.5 hours of symptom onset
2. Intracranial haemorrhage excluded (using imaging)
What management needs to be in place to prevent complications from stroke?
Swallowing and speech assessment DVT prophylaxis Pressure areas Continence Infection prevention Contractures Pain Depression
What secondary prevention strategies can be used in management of stroke patients?
Aspirin/ clopidogrel Statins BP control Anticoagulants (e.g. if AF) Smoking cessation Heart disease/ Diabetes management
What are the common causes of TIA?
Lack of perfusion due to carotid artery or vertebrobasilar insufficiency
What is the ABCD2 scale used to assess?
Risk of stroke following a TIA
What factors are assessed when using the ABCD2 scale?
Age (>60 = 1 point) BP (>140/90mmHg = 1 point) Clinical features (unilateral weakness = 2 points, speech problems with no weakness = 1 point) Duration of symptoms (>60 mins = 2 points, 10-59 minutes = 1 point) Diabetes (1 point)
What ABCD2 score would indicate a high risk of stroke?
4+ points on ABCD2
2 TIAs in close succession (crescendo TIA = multiple TIAs in increasingly closer succession)
What is rehabilitation?
Process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimum physical, psychological and social function
What type of cerebral haemorrhage is most likely following a blow to the chin?
Subdural haemorrhage caused by the brain rebounding off the skull from the blow (known as a contrecoup injury)
Why could you see symptoms presenting later in a haemorrhagic stroke in the elderly?
Cerebral atrophy common with ageing allowing more room to accommodate increased volume from bleed thus seeing a slower increase in intra-cranial pressure
What is the MoA of Alteplase?
Activation of Plasminogen to Plasmin which breaks Fibrinogen to Fibrin, breaking down clot
